Key factors for establishing and sustaining a successful palliative radiation oncology program: a survey of the Society for Palliative Radiation Oncology

Introduction

The goal of palliative care is to provide relief of physical pain, psychological, spiritual, and social suffering (1) for persons and their families living with serious illnesses. This goal can be achieved both through supportive care provided during any part of a patient’s cancer journey, not only during hospice care when the end of life is near. Palliative radiotherapy is radiation therapy (RT) that is employed to ameliorate or prevent pain, neurologic or other symptoms caused by cancer (2,3) in the setting of advanced, non-curable illness. It is a critical component of high-quality palliative care and can have a dramatic impact on an individual’s quality of life when utilized appropriately and in a timely manner.

Radiation is delivered with palliative intent to approximately 40% of all radiation oncology (RO) patients worldwide; nearly 3.7 million patients in the US receive palliative RT as part of their cancer treatment (4-8). As a part of the continuum of cancer care, all members of a patient’s treatment team, including radiation oncologists, have the opportunity to assess and treat these cancers related symptoms in order to relieve suffering and improve quality of life of the patient and their family in the context of “palliative radiation oncology programs”, and many such programs exist across the country and the world (9-26). These programs work to improve access to care for advanced cancer patients that reduces time from consult to treatment (11,14,24), allows for upstream advanced directive documentation (27-29) and goal-aligned care, and promotes multi-disciplinary care (23,25,30). In doing so, these programs can provide acute pain and symptoms relief and improve the likelihood of RT completion by reducing pain and discomfort during treatment and keeping RT courses short and manageable.

A comprehensive review of the current state of palliative RO programs is required to champion their integration into the clinic (31). Therefore, we undertook a survey of RO members of the Society for Palliative Radiation Oncology (SPRO) to define the characteristics and role of palliative radiation oncology programs (PROPs) in a variety of practice settings, to identify what resources are critical and helpful for creating and sustaining a successful PROP, and to identify obstacles for developing and maintaining active PROP programs. These survey results may help inform, spur development of, and facilitate implementation of standardized guidelines for PROP development. We present this article in accordance with the STROBE reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-23-499/rc).

Methods

A 15-item survey instrument was authored by a national group of experts in palliative RO representing both academic and community practice. The electronic survey was sent via email to 157 physician members of SPRO in July 2019. Responses were reviewed for identification of duplicates from the same practice using zip code and practice characteristics. When asking about palliative RO programs, the definition of a PROP remained broad to ensure inclusion of all types of programs that are focused on the use of effective palliative RT.

Respondents were asked to identify practice characteristics, including distance to nearest tertiary or large academic center, numbers of physicians, residents, physician extenders, nurses, LINACs, and the zip code or country of practice.

Respondents were asked to describe their practice facility and indicate the perceived importance of dedicated PROPs to the field of RO on a Likert scale ranging from one to five, representing: [1] not important; [3] neutral; and [5] most important. Next, respondents were asked to identify whether or not their practice had a PROP; and if not, what efforts were or were not being taken to establish one.

Those with a PROP were asked to describe it, rate which resources were essential and which dedicated treatment team members were essential. Of those with a PROP or those who have tried to start one, respondents were asked to identify perceived barriers to initiating a PROP as well as maintaining a PROP. In addition, those without a PROP were asked to identify which resources would help in starting one. All respondents were asked to identify which tools were used in their program.

Items of agreement were rated on a Likert scale ranging from one to five, representing: strongly disagree [1], disagree [2], neutral [3], agree [4], and strongly agree [5]. Descriptive statistics including mean (SD) and median (IQR) response ratings were determined for each response and summarized to include the proportion of respondents providing top scores (4 or 5 out of five) for each question.

Due to the small sample size, detailed statistically analysis was not performed and simpler descriptive statistics were calculated.

Study data were collected and managed using REDCap, an electronic data capture tools hosted at the Icahn School of Medicine at Mount Sinai (32,33). REDCap (Research Electronic Data Capture) is a secure, web-based software platform designed to support data capture for research studies (32,33). Analyses were performed using SPSS (IBM Corp.; Armonk, NY, USA).

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the institutional review board at the Icahn School of Medicine at Mount Sinai (IRB# 18-01080), and written consent was waived due to the anonymous nature of the survey.

Results

The survey was emailed to 157 members, and 48 (31%) responded. Demographics of respondents are shown in Table 1. Most respondents practiced at an academic center (71%) or satellite (15%) and in a larger group practice (≥6 physicians, 75%). No duplicates from the same practice were identified.

Most respondents (89%) believed the development and growth of a dedicated PROPs was either important (50%) or most important (39%) to the field of RO. Only 17 (36%) respondents had a PROP in their place of practice and of those without a PROP, 18 (38%) expressed a desire to establish one and 6 (13%) were currently developing one (Table 2).

Of those respondents with PROPs (N=16), the median program length was 5 years (IQR: 5–8 years). A majority had an ability to refer to an outside palliative care specialist (65%), an outpatient service (53%), and specialized clinical processes for managing palliative patients (53%), with 41% having an inpatient service. Resources considered most essential (agree/strongly agree, 94%) were access to a palliative care specialist, a radiation oncologist with an interest in palliative care, having an outpatient palliative RO clinic, availability of an advanced practice provider, a focus on short course regimens, and availability of educational opportunities (see Table 3).

After initiating a PROP, most institutions (75%) noticed an increase in the number of new referrals for palliative RT (25% with >50% increase, 18.8% with 26–50% increase, and 31.3% with 1–25% increase), while the other 25% reporting a stable number of referrals. No program reported a decrease in the number of referrals. A majority of existing PROPs (66%) did not employ formal tools of life expectancy in the routine management of patients. The most common tools utilized by PROPs include treatment workflows (including expedited workflows, see Table 4).

Of those with a PROP or those who have tried to start one, greatest perceived barriers to initiating a PROP were committed resources (83%), dedicated clinical time to see urgent consults (61%), difficulty coordinating timely management of patients (61%), and lack of support from departmental leaders/colleagues (61%) (Table 5). Perceived barriers to sustaining a PROP were similar.

For those without a PROP, the perceived most important resources for building a program included access to a palliative care specialist by referral (83%), availability of dedicated mid-level support, published guidelines with best palliative RO practices (80%), educational materials for referring physicians and patients (80%), educational sessions for clinical staff (83%), and standardized clinical pathways (80%) (Table 6).

Discussion

Over the past two decades, there has been an increasing interest, awareness, and utilization of integrated palliative care programs in oncology spurred by multiple studies showing that this paradigm leads to improvements in quality of life, cost savings, patient satisfaction, and even survival (34-37). Along with this shift has come opportunities for integration and cooperation among oncologic and palliative medicine disciplines. RO is an obvious partner as a high percentage of radiation treatments are delivered with palliative intent with many patients having a high symptom burden arising from discrete targetable metastatic disease. Some of these partnerships have resulted in the creation of palliative RO programs that meet patient’s specific palliative radiation needs, which in turn have shortened treatment times, increased access to care, shortened hospitalizations, reduced costs, and improved the quality of care (19,20). Since they are designed to address specific needs unique to each of the departments or practice of origin, there is great variation in the phenotype of PROPs ranging from programs that house palliative inpatient services to those that focus on outpatient rapid-access programs, to larger models that encompass both. Due to the perceived benefits and advantages as well as mentorship from experienced PROP experts nationwide, interest and utilization of PROPs has grown over the years.

About 50% of respondents to the current survey reported wanting to or are currently advocating and in the process of establishing a PROP at their institution, in addition to the 36% which already have a program. Likewise, most (89%) respondents to this survey felt that PROPs are important for the field of RO. This is also in concordance with a recent systemic review addressing perceptions about palliative care among radiation oncologists, that showed 100% of identified articles confirmed the importance of palliative care in RO (38). PROPs fill important roles in patient care and supportive cancer management; gaining a greater understanding of successful practices may help with their implementation and sustainability.

The development and sustainability of a PROP requires significant support and resources. This project identifies multiple notable factors that were felt by those with an active PROP, to be most essential for sustaining success. These factors range from personnel requirements (access to a palliative care specialist, a radiation oncologist with an interest, dedicated mid-level support) to process/logistics initiatives (standardize patient care pathways, focus on short course RT, dedicated simulation and treatment slots) to continuing education opportunities. Among these important features, access to a palliative care specialist either integrated into the program or available for consult aid in patient management and allow for more engagement of radiation oncologists in the multidisciplinary team. Due to these improved connections and communication, PROPs have been shown to increase the likelihood of timely palliative care referrals (19) and an increase in overall quality of palliative cancer care (16). Specialized support personnel like a dedicated nurse practitioner or a clinical specialist radiation therapist are considered standard components to many successful PROPs and can provide continuity of care, logistic/administrative support, improved communication, and increased capacity to engage in patient care (15,16,19,39-42). Lack of these supports is considered a significant barrier. Likewise efforts and processes to standardize clinical workflows, improve treatment logistics, and systematize support and timely referrals to palliative medicine specialist and other supportive services all fall within the bounds of PROPs and are essential for their success (15). PROPs also provide opportunities for continued education in palliative care skills and techniques, gives further support for to the program, and compensating for some of the lack of required palliative care training among radiation oncologists (15,43).

Initiating and sustaining a new PROP is a matter of balancing multiple elements and priorities of shareholders simultaneously, but there is little available data investigating barriers that hinder implementation. In our study we identified that the key barriers to implementation and sustainability were: an inability to garner sufficient clinical resources; inability to carve out dedicated blocks of clinical time for clinicians to see, simulate, and treat urgent patients; difficulties managing coordination of patient care; and, challenges in securing buy in from administrators and department chairs. Further study investigating practical methods for overcoming these barriers is needed.

As previously noted, a variety of resources are necessary to implement a PROP. For institutions without a PROP some of the resources that were felt to have the most potential benefit related to the guidelines, logistics, workflow, and business aspects of the program, as well as the educational components for program members, referring physicians and patients. Clearly institutions want to know the framework necessary to build effective and sustainable PROPs. To this end, efforts to generate and publicize this type of information will provide valuable insights and help lay a foundation for the success of new PROPs in the future and should be a focus of future scholarly activity.

One key aspect to starting a new program is how this may financially impact their department. In this study, most institutions who created PROPs reported an increase in the number of palliative RT referrals after starting their program. Seventy-five percent of programs reported increase in the number of referrals with a quarter of all programs experiencing greater than 50% increase in referrals. This is in concordance of the increase seen by other programs. For the first US-based palliative radiation program at the Dana-Farber/Brigham and Women’s Cancer Center, they reported a 60% increase in referrals in their first year (15). At Vanderbilt, the number of consults increased by 35% in the first 10 months (20) and the Mount Sinai PROP reported a near doubling of referrals. At Toronto-Sunnybrook Odette Cancer Center, they reported a 16% increase in the number of administered palliative courses of radiation in their first year and an increase from 200 to 500 cases per year over 8 years after starting their rapid response palliative radiation program (11). Additional growth benefits for institutions also include increased referrals to other support services like home nursing, social work, nutritional counseling, occupational health, palliative medicine, hospice and even clinical trial enrollment (31).

Limitations

There are limitations to our study that are important to note. The survey was distributed to SPRO members which may not capture all practicing radiation oncologists in the country who are involved in PROPs. About one third of the people who received the survey responded, so the data may not fully represent all barriers or resources to consider when developing a PROP. Part of the low response rate could also be that the SPRO membership includes many residents who may not have responded. Likewise, the relatively small numbers of respondents may limit the statistical power of the results and limit a more detailed statistical analysis. Additionally, the survey was completed in 2019 and prompt report was delayed due to the COVID pandemic. As a result, some of the practices regarding PROPS may have changed pre vs post pandemic, but the topic and the information remains very relevant. Despite these limitations, this study provides valuable insight into currently perceived barriers and facilitators to establishment of a PROP and highlights potential opportunities for radiation oncologists looking to increase the likelihood of successful implementation and sustainability of these programs.

Conclusions

While some successful PROPs exist and the benefits for patients are well-known, absence of widespread adoption of PROPs represents a missed opportunity to optimize care for patients with advanced cancer. Currently, most PROPs exist within academic centers, are in outpatient setting, have access to palliative specialists by referral, and have specialized clinical processes for palliative patients. Our study highlights that a lack of committed resources was the single most important perceived barrier for implementing or sustaining a PROP. Availability of best practice guidelines, educational resources, access to palliative care specialists and standardized clinical treatment pathways are most important for those who wish to develop a PROP. PROPs can provide opportunities to improve care and address the specific palliative care needs at any institution. If PROPs are to be a successful model of care delivery, concerted efforts to champion their implementation and sustainability are critical. This should include efforts to reduce the identified barriers and further define key logistical components and best practices. These insights can inform discussions and help align resources to develop, grow, and sustain successful PROPs.

Acknowledgments

This work was accepted for an oral presentation at the 2020 American Radium Society Meeting, which was cancelled due to the COVID-19 pandemic, and the abstract was published in the conference proceedings in the International Journal or Radiation Oncology, Biology, and Physics in Oct, 2020.

Funding: The authors were partially supported by the National Institutes of Health (T32CA225617, D.C.M.; 5P30AG028741, 5K76AG068516, K.D.; 5R01AR075964 T.B.). The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine for the series “Palliative Radiotherapy Column”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-23-499/rc

Data Sharing Statement: Available at https://apm.amegroups.com/article/view/10.21037/apm-23-499/dss

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-23-499/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-23-499/coif). The series “Palliative Radiotherapy Column” was commissioned by the editorial office without any funding or sponsorship. C.J. served as the unpaid Guest Editor of the series and serves as the unpaid co-Chair of the Palliative Radiotherapy Subcommittee of Annals of Palliative Medicine from February 2022 to January 2024. S.S.L. serves as the unpaid Associate Editor-in-Chief of Annals of Palliative Medicine from February 2022 to January 2024. K.D. and Y.D.T. serve as the unpaid editorial board members of Annals of Palliative Medicine from February 2022 to January 2024. J.A.J. and T.B. serve as the unpaid members of Palliative Radiotherapy Subcommittee of Annals of Palliative Medicine from February 2022 to January 2024. D.C.M. received NIH/OD Grant (DP5OD031876). K.D. received NIH/NIA Paul Beeson Award (K76 AG068516). Y.D.T. reports that he received speaking honorarium from ASTRO for Spring Refresher; reports Committee work: Chair Palliative Care Track ASTRO scientific session, Chair PCG lymphoma Committee, and Co-Chair PTCOG lymphoma Committee (None related to this project). J.S. received consulting fees from MIM (auto-contouring, not related to current work), and is a Board Member for Down Syndrome Association of Wisconsin. S.S.L. received research funding (he is co-PI) from Kuni Foundation, and funding from Hutchinson Center as Lead Academic Participating Site (UG1 CA 233328); was invited as a guest speaker in the Japanese Society for Radiation Oncology (JASTRO) annual meeting 2022; is a Member of Board of Directors and Medical Director of Distinction in Practice in Stereotactic Radiotherapy Program of Radiosurgery Society, and Assistant Councilor and Chair of CARROS Nominating Committee for American College of Radiology. J.R.R. reports research support from Rowpar Pharmaceuticals, speaking honorarium from the Arizona Dental Association, and support to attend the Alpha Tau investigators’ meeting (no conflicts related to this project). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the institutional review board at the Icahn School of Medicine at Mount Sinai (IRB# 18-01080), and written consent was waived due to the anonymous nature of the survey.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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